Alfaxalone Facts
3/1/2020
ALFAXALONE FACTS
Fernando Garcia-Pereira DVM, MS, DACVAA Veterinary Anesthesia Services (VAS)-JAX [email protected]
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Characteristics • Neurosteroid in Cyclodextrin • One of the steroid anesthetics found in Saffan®
• Acts on the GABAA receptor – Unconsciousness and muscle relaxation
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Cardiovascular Effects • Similar cardiovascular effects to propofol – HR – or C.O. (dose dependent) – BP (vasodilation)
Veterinary Anaesthesia and Analgesia, 2008, 35, 451-462 Cardiorespiratory and anesthetic effects of clinical and supraclinical doses of alfaxalone in dogs W Muir, P Lerche, A Wiese, L Nelson, K Pasloske, T Whittem 3
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Cardiovascular Variables
HR MAP Cardiac Index 150 80 200 75 100 Alfaxalone Alfaxalone Alfaxalone 70 100 50 Propofol Propofol Propofol 65 0 60 0
J Am Vet Med Assoc. 2019;254(12):1421-1426 Recovery characteristics of dogs following anesthesia induced with tiletamine- zolazepam, alfaxalone, ketamine-diazepam, or propofol and maintained with isoflurane. Hampton CE, Riebold TW, Mandsager RE. 4
Cardiovascular effects during CRI • Dose dependent cardiovascular and respiratory depression • Similar to propofol
AJVR, 2008, 69(11): 1391-8 Comparison of the anesthetic efficacy and cardiopulmonary effects of continuous rate infusions of alfaxalone-2-hydroxypropyl-beta-cyclodextrin and propofol in dogs Ambros B, Duke-Novakosvski T, Pasloske KS 5
Respiratory Effects • Dose dependent: – Respiratory depression • Hypercapnea is common – Decrease in PaO2 • hypoxemia can occur, oxygen supplementation is advisable – Apnea –MOST COMMON SIDE EFFECT!!! » Always have endotracheal tubes with you and a anesthetic machine ready
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APNEA • Most common side effect independent of route of administration
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Neurologic Effects • CNS friendly • Excitation in cats during recovery (IM route) • Longer duration compared to propofol
Br J Anaesth. 1985 Apr;57(4):369-74. Use of a continuous infusion of althesin in neuroanaesthesia. Changes in cerebral blood flow, cerebral metabolism, the EEG and plasma alphaxalone concentration. Bendtsen A, Kruse A, Madsen JB, Astrup J, Rosenørn J, Blatt-Lyon B, Cold GE.
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APGAR SCORES Percentage of puppies in each score category within 5 minutes of birth 80% 60% 40% 20% 0% Severe distress Moderate distress No distress Alfaxalone Propofol
Theriogenology, 80 (2013): 850-854 Apgar score after induction of anesthesia for canine cesarean section with alfaxalone versus propofol A. Doebelia, E. Michela, R. Bettschartb, S. Hartnackc, I.M. Reichlera 9
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Theriogenology • Allopregnanolone analog • Potential protective effect in premature fetus when labor is induced by glucocorticoids (Betamethasone)
Neuropharmacology. 2014 Oct;85:342-8. The effects of betamethasone on allopregnanolone concentrations and brain development in preterm fetal sheep. Yawno T, Mortale M, Sutherland AE, et al.
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Quality of Anesthesia Recovery • Smooth recovery for propofol and alfaxalone • Poorer with Ketamine/diazepam and Telazol
Note: Alfaxalone half-life is longer than propofol
J Am Vet Med Assoc. 2019;254(12):1421-1426 Recovery characteristics of dogs following anesthesia induced with tiletamine- zolazepam, alfaxalone, ketamine-diazepam, or propofol and maintained with isoflurane. Hampton CE, Riebold TW, Mandsager RE. 11
Doses
• Dose – Cat: 2-5 mg/kg IV 3-5 mg/kg IM – Dog: 1-3 mg/kg IV 1-3 mg/kg IM (limited by volume in large dogs)
Vet Anaesth Analg. 2017 Jul;44(4):794-802 Intramuscular injection of alfaxalone in combination with butorphanol for sedation in cats. Deutsch J, Jolliffe C, Archer E, Leece EA.
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Cardiorespiratory Neurologic • Similar cardiovascular • CNS friendly effects to propofol • Potential protective effect – HR in premature fetus when – or C.O. (dose labor is induced by dependent) glucocorticoids – BP (vasodilation) (Betamethasone) • • Dose dependent Excitation in cats during respiratory depression recovery (IM route) • – Apnea after bolus Longer duration compared to propofol
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• No difference between the cardiovascular and respiratory effects of propofol and alfaxalone • NO support alfaxalone safer than propofol • Same safety precautions: – Endotracheal tubes, oxygenation, anesthesia machine available and MONITORING!!
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Opinion • Can be use interchangeably with propofol • Main advantage: CAN BE GIVEN IM – Great substitute for Ketamine (in cats) • Careful with apnea and overdose during induction (dose dependent hypotension)
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CAPNOMETRY: CLINICAL INTERPRETATION OF VALUES AND WAVEFORMS
Fernando Garcia-Pereira DVM, MS, DACVAA [email protected]
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DEFINITION OF CAPNOGRAPHY
• Graphic representation of respiratory CO2 • EtCO2 is the expired pressure of carbon dioxide
• EtCO2 is an approximation of PaCO2
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Alveol i
vein PACO2 artery
PvCO2 PaCO2
Capillary 3
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VENTILATION/PERFUSION RATIOS
PACO2= 0 PACO2 = PaCO2
PvCO2 = PaCO2 Hypoperfusion Normal Atelectasis
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Mouth Piece ETCO2
Airway
PACO2
PaCO2 5
END TIDAL CO2 – ETCO2
1- PaCO2 ~ PACO2
2- EtCO2 ~ PACO2 EtCO2 EtCO2 ~ PaCO2
P CO = P CO PACO2 A 2 a 2
PaCO2
Normal
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LEARNING ASSESSMENT!!
•Healthy 2 year old Lab recovering from a TPLO. After oxygen is removed SpO2 is low (88%). Differentials? Most likely? Diagnostic planning…
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DIFFERENTIALS FOR HYPOXEMIA
• HYPOVENTILATION (>45 mmHg PaCO2) • V/Q mismatch (atelectasis) • Alveolar diffusion barrier • R-L Shunt (vascular anomaly)
• Low inspired oxygen concentration (below 21% of O2)
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DIAGNOSTIC PLANNING
HYPOVENTILATION • Check PaCO2 for abnormality • Can use ETCO2 • Can use Blood Gas (BETTER $$$) • Why not try first the ETCO2? • Specially if still intubated • Can still do even if not intubated
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POSSIBILITIES OF ETCO2 VALUES
Higher than Lower than normal Normal normal (Hyperventilation) (Euventilation) (Hypoventilation)
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POSSIBILITIES OF ETCO2 VALUES
Lower than normal Normal EtCO2 EtCO2 Higher than But way higher normal But way higher PaO2 But higher PaO2 PaO2
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WHAT TO LOOK FOR:
DURING ANESTHESIA (100% O2) DURING RECOVERY (21% O2) • Animal panting with normal • PulseOxi at low 90s or below temperature 90% • Tachycardia and Tachypnea • Animal seems still very sedated • Seems light but at expected or • Potential over use of opioid higher concentration of inhalant (CRI) or recent dose of one • Hypertensive • Obese animal • Non opioid responsive
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FACTORS AFFECTING ETCO2
PROCEDURES PATHOLOGIES • THORACOTOMIES • GDV • LAPAROSCOPIES • RESPIRATORY Dz • TRENDELEMBURG • OBESITY POSITION • CARDIOVASCULAR Dz • SOME ORTHOPEDIC JIGS
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APPLICATIONS FOR ETCO2 MONITORING
• CO2 analysis can assess (EtCO2 vs PaCO2) • Ventilation • Metabolism • Cardiovascular status • Equipment/ patient problems
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CAPNOMETRY
Equipment Design • Mainstream • Side stream
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MAINSTREAM
• Infrared • Light Absorption • Dissimilar atoms
• Cannot measure O2
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MAINSTREAM
Advantages Disadvantages • Less maintenance • Fragile sensor • Less disposable parts • Adds weight on tube • No scavenging • Adds dead space • Fast response time • Longer warm up time • No standard gas • Measure CO2 only
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MAINSTREAM
False low Et CO2
Correct
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SIDESTREAM
• Infrared, • Mass Spectrometry • Raman Spectrometry
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SIDESTREAM Advantages Disadvantages • Possible multi gas analysis • More disposable parts • Away from patient • Longer response time • Inexpensive and light • Calibration cylinder interface • Scavenging required • Water Trap
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CAPNOMETRY BENEFITS
• Proper Intubation • Malfunction • System Integrity • Respiration/Circulation • Rebreathing • Respiratory depression • Change in Metabolic Rate • Best tool during CPR
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CHEMICAL COLORIMETRIC ANALYSIS
• pH sensitive chemical indicator • Useful to check: • Changes color with change in pH • Intubation • Not quantitative!! • Apnea
• Careful with contamination • Careful with low CO2 • Easy Cap II (< 0.5%)
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NORMAL CAPNOGRAPH
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HYPERCAPNEA
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REBREATHING
CAREFUL WITH SIDESTREAM! TRULY REBREATHING?
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AIRWAY OBSTRUCTION
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SAMPLING LINE LEAK AND IPPV
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BLOOD LOSS
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CAPNOMETRY
• Factors affecting accurate ETCO2 measurement • Ventilation/Perfusion status • Open thorax • Integrity and type of machine • Contamination • Equipment error
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CONCLUSION Great tool Careful use • Proper intubation • May underestimate • Apnea PaCO2 • Cardiorespiratory • May require blood gas and metabolic status for true ventilatory assessment (PaCO ) • Equipment integrity 2
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